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PhotDgraphic 

Sciences 
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da  I'angle  supArieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  nicessaire.  Les  diagrammer  suivants 
illustrent  la  mAthode. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

n^k 


The  Methods  Employed  in  Examin- 
ing the  Eyes  for  the  Detection 
of  Hysteria 


rip«eiited  to  the  Hectioii  on  NeuroloKy  and  Medical  Jurisprndence,  at  tl»e 
Forty-nintli  Annnal  Meeting  of  the  American  Medical  Associa- 
tion held  at  Denver,  (.'olo..  June  7-10.  1898. 


BY  CASEY  A.  WOOD,  M.D. 


(■Ht(;AOO. 


REPRrNTED  FROM 

THE  JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION, 

NOVEMBER  i.',  1S98. 


OHICAGO: 

American  Medical  Association  Pkess. 

1898. 


■'•*'^,..^i^s?5!aiHaj»ffi«sse^^ 


THK  METHODS  EMPLOYED  IN  EXAMINING 

THE   EYES  FOR  THE  DETECTION 

OF  HYSTERIA. 


'33 


BV  CASEV  A.  WOOD,  M.D. 


Although  much  has  been  written  regarding  the 
vaUie  of  the  ocular  signs  and  symptoms  of  hysteria  in 
the  difignosis  of  that  disease,  I  believe  there  is  good 
reason  for  returning  to  several  matters  in  this  connec- 
tion that  seem  to  me  of  vital  importance,  especially  as 
I  do  not  think  sufficient  stress  is  commonly  laid  upon 
the  means  by  which  one  must  arrive  at  diagnostic 
conclusions. 

My  own  belief,  after  a  somewhat  extended  acquain- 
tance with  this  disease  is,  that,  if  one  were  to  make  a 
special  study  of  that  organ  that  m(-)8t  uniformly  exhib- 
its the  evidence  of  hysteria,  the  eyv  would  afford  the 
most  informatitjn,  even  more  emphatically  than  the 
skin  or  the  mucous  membranes.  On  the  other  hand, 
anomalies  of  the  general  sensibility  are  probably 
more  easily  detected  by  the  average  individual  (who 
methodically  searches  for  them)  than  are  ocular 
defects.  But  as  the  scientific  observer  omits  no  ex- 
amination that  will  assist  him  in  arriving  at  proper 
C(Miclusions  in  diagnosis,  prognosis  or  therapy,  I  enter 
a  plea  for  a  mori!  thorough  and  more  general  use  of 
certain  methods  employed  by  the  ophtTialmologist  in 
detecting  the  presence  of  ocular  hysteria  as  one  man- 
ifest of  the  general  neurosis. 

First  of  all,  then,  what  are  the  commonest  ocular 
manifestations  of  hysteria,  what  the  most  reliable 
means  for  their  detection,  and  how  may  errors  in 
examination  be   avoided?     I   need   hardly   say   that 


Bonie  acciuaintjince  with  the  use  of  the  ophth 
scope  is  of  ^reat  value  in  the  dingnosisof  ooulai 
teria,  and  in  investigating  the  wubjoct  one  shou 
cartain  that  there  are  no  alterations  in  the  inter 
the  eye  to  account  for  the  visual  disturbancet 
is  not  fitting  that  I  should  point  out  the  val 
ophthalmos(^opic  examinations  to  the  trained  m 
ogist:  I  do  not  very  well  see  how  he  can  disj 
with  them.  Should  he  be  unable  to  examiu( 
background  of  the  eye  with  the  mirror  he  shou 
all  events,  seek  a  report  upon  the  condition  ol 
fundus  at  the  hands  of  some  oonfr6re  expert  in 
work.  As  is  the  case  with  other  organs  of  the  1 
there  are  absolutely  no  tissue  alterations  to  be  f 
in  any  part  of  the  eye,  due  to  the  presence  of  hys 
A  negative  report  upon  the  fundus  conditio] 
therefore,  a  si'nr  qua  noii  in  examining  a  suspi 
hysterope. 

ANOMALIES  OF   ACX'OMMODATION. 

Taking  one  age  with  another,  the  commonest  o 
sign  of  hysteria  is  a  defect  in  the  focusiiig  pow 
the  eye — anomalies  of  accommodation,  ^r  va 
reasons  these  conditions  have  been  called  A/y/; 
uisufficicncy  of  accommodation,  ciliary  parcs^ 
paralysis,  painful  accomimxhttion,  nervous  as 
opia,  etc.  The  patient  complains  of  the  usual  s; 
toms  of  asthenopia — pain  in  the  eyes  and  fore 
when  attemx^ting  to  read  or  do  any  other  near  \ 
blurring  of  print,  photophobia,  frequent  winking 
These  cases  are  rarely  permanently  relieved  by  gT 
or  by  an  exclusive  lo(^al  treatment  of  the  eye.  I 
there  is  a  defect  in  the  range  of  accommodntion. 
so-called  paresis  of  accommodation  is  nearly  al 
in  the  form  of  a  true  hysteric  contracture  of  the 
iary  muscle-  the  motor  power  by  which  the  e^ 
focused  for  various  distances.  The  nearest  poin 
which  the  eye  can  accommodate  itself  for  the  dis 
seeing  of  small  objects  varies  with  the  age  of  the 
vidua!.  As  you  are  well  aware,  this  point  is  < 
close  to  the  eye  in  childhood,  remote  from    it  ii 


n^ 


*o  of  flu'  ophtlialmo- 
ignosie  of  ocular  hys- 
ubject  one  should  be 
one  in  the  interior  of 
iial  disturbances.     It 
int  out  the  value  of 
1)  the  trained  neurol- 
ow  he  can  dispense 
able  to  examine  the 
mirror  he  should  at 
he  condition  of  the 
nfr^re  expert  in  that 
•  organs  of  the  body, 
derations  to  l)e  found 
presence  of  hysteria, 
undus  condition   is, 
imining  a  suspected 

«()I>ATI()N. 

he  commonest  ocular 
lie  focusiiig  power  of 
>dation.     For  various 
been  called   hysteric 
,   ciluiry  paresis   or 
on,    nervous  asthni- 
8  of  the  usual  symp- 
B  eyes  and  forehead 
ny  other  near  work, 
equent  winking,  etc. 
y  relieved  by  glasses 
t  of  the  eye.     In  all 
icommodntion.   This 
ion  is  nearly  always 
ntracture  of  the  cil- 
y  which  the  eye  is 
he  nearest  point  for 
tself  for  the  distinct 
the  age  of  the  indi- 
this  point   is   quite 
lote  from    it  in  old 


3 


nge.  On  the  other  hand,  every  eye  has  a  certain  range 
of  accommodation ;  that  is,  there  is  a  certain  space 
within  which  small  objects  ean  be  distinctly  seen,  and 
when  the  eye  is  normal,  or  when  the  refraction  is  ren- 
dered normal  by  distance  glasses,  this  range  is  singu- 
larly and  wonderfully  constant  in  individuals  of  the 
same  age,  and  I- believe  that  the  neurologist  who  is  on 
the  lookout  for  devialions  from  the  normal  accommo- 
dations will  obtain  assistance  in  diagnosis  by  bearing 
this  fact  in  mind  For  all  practical  purposes,  how- 
ever, one  may  ignore  the  extent  of  this  accommoda- 
tive range  and  confine  one's  attention  to  the  nearest 
point  of  distinct  vision,  that  is  almost  always  affected 
in  hysteria,  that  is  to  say,  is  usually  too  near  or  too 
far  away  from  the  eye  of  the  hysterope.  The  follow- 
ing table  indicates  the  proper  distance,  and  it  is  a  very 
easy  thing  to  determine  any  deviation: 

Nearest  point  of 
Akb.  difltinct  vision. 

10 7      cm. 

15 8 

20 10 

25 11.7     " 

30 14      um. 

35 18 

40 22 

45 28.0     " 

50 40.5     " 

An  eye  that  is  under  the  influence  of  hysteria  acts 
either  as  if  it  were  under  the  influence  of  pilocarpin 
or  atropin;  the  patient  is  able  to  read  fine  print  either 
abnormally  near  or  sees  small  objects  most  distinctly 
farther  away  than  he  should. 

In  practice,  all  that  it  is  necessary  to  do  is  to  have 
tlie  distant  vision,  if  abnormal,  corrected  by  glasses 
and  then  ask  the  suspected  individual  to  read  the 
finest  diamond  print,  held  as  near  to  the  eye  as  possi- 
ble. The  patient,  with  his  back  to  a  good  light,  is 
asked  to  read  a  portion  of  a  page  of  this  print,  at  the 
normal  distance  from  the  eye,  as  shown  by  the  table. 
If  he  continues  to  read  it  when  brought  a  couple  of 
centimeters  or  more  nearer,  or  if  he  cannot  read  un- 


loBH  it  is  vem*»ved  fftrther  away  than  the  n<>rrnal 
tance,  a  defect  of  accommodation  is  certainly  pren 
I  recommend  this  as  one  of  the  most  satisfactory 
most  easily  applied  of  all  the  tests.  As  in  other  fo 
of  spasm  or  paralysis  of  accommodation,  the  co 
tion  may  often  he  relieved  by  glasses.  It  often  1 
pens  that  a  youn^'  subject  must  be  treated  as  it 
were  sixty  years  of  a^e,  requiring  a  strong  cor 
glass  for  reading'  at  the  normal  distance  or  a  cone 
glass  for  street  wear.  In  both  instances  a  few  di 
of  a  1  per  cent,  solution  of  atropia  will  disclose 
true  refraction,  often  unmasking  the  hysteric  chara 
of  the  defect. 

DEKKCTS    IN   THK    FIELD   OF    VISION. 

As  every  neurologist  knows,  defects  in  the  fiel< 
vision  constitute  some  of  the  commonest  signi 
disease  of  the  ocular  apparatus,  and  that  they  ai 
paramount  importance,  while  a  knowledge  of  t 
peculiarities  is  of  great  value  in  determining 
presence  of  hysteria.  For  purposes  of  comparisc 
show  two  perimeter  charts:  one  of  the  normal 
and  the  other  furnished  by  a  hysteropo  under  my  ( 
The  predominant  peculiarity  of  an  hysteric  anor 
of  the  visual  field  is,  that  while  in  every  other dis 
(except  hysteria)  where  peripheral  limitations  oc 
the  color  field  is  atfected  pari  fHtssn,  or  in  n  gn 
proportion  than  the  field  for  white.  In  non-hysl 
diseases  perception  of  color  is  often  entirely  lost, 
yet  fairly  large  areas  susceptible  to  visual  sensa 
from  a  white  disc  remain.  In  hysteric  amblyopin 
field  for  colors  is  of  greater  extent  or  is  less  afle 
proportionately  than  the  field  for  white  objects, 
fhc  rererse  of  tliaf  irliirh  (ihtains  in  other  tier 
(iJJ'cctiotts.  Kven  where  the  field  for  white  is  still 
largest  it  can  usually  be  shown  (when  there  is 
perimetric  defect)  that  the  visual  field  for  red  is  la 
than  that  for  blue,  and  measurements  for  these  c( 
should  always  be  made  in  doubtful  cases.  On 
the  best  examples  of  this  reversal  of  the  color 


/37 


lan  the  norninl  die- 

ie  certainly  preHeiit. 

oat  satisfactory  and 

V    As  in  other  forms 

lodalion,  the  condi- 

B8VB.     It  often  liap. 

bo  freated  as  if  he 

IK  a  strong  convex 

intance  or  a  concave 

stances  a  few  drops 

>ia  will  disclose  the 

le  hysteric  character 

OF    VISION. 

fects  in  the  field  of 
ioniinonest  signs  of 
md  tliat  they  are  of 

knowledge  of  tlieir 
in  determining  the 
ses  of  comparison,  I 
of  the  normal  field 
)ropo  undei-  my  care, 
m  hysteric  anomaly 
1  eveiy  other  disease 
il  limitations  occnr, 
ssn.  or  in  a  greater 
e.  In  non-hysteric 
[•n  entirely  lost,  and 
to  visual  sensation 
iteric  amblyopia  the 
t  or  is  less  affected 

white  o])jects, ///8/ 
IS  in  other  ncrrous 
For  white  is  still  the 
when  there  is  (niij 
field  for  red  is  larger 
)nts  for  these  colors 
tful  cases.  One  of 
I  of  the  color  field 


occurred  in  the  case  of  a  young  lady,  aged  17,  in  deli- 
cate health,  who  began  to  complain  of  her  eyes.  She 
then  noticed  that  she  could  not  see  well  in  the  distance 
or  read  ordinary  print  with  the  right  eye.  There  were 
no  fundus  changes;  patient  was  distinctly  hysteric; 
had  attacks  of  weeping-without  apparent  cause,  phar- 
yngeal" anesthesia,  lump  in  her  throat,  etc.  She  had 
spasm  of  accommodation,  was  able  to  read  only  (!oarse 
print  and  that  at  from  <)  to  10  cm.  in  front  of  tlie  ey«'. 
She  could  not  read  line  print  at  any  distance.  I  wish 
you  would  especially  notice  that  her  field  for  red  is 
larger  than  that  for  white. 

It  must  be  remembered,  that  even  where  the  patient 
does  not  complain  of  visual  disturbances  (juite  marked 
defects  of  indirect  vision  may  be  present.  If  these 
do  not  proclaim  themselves  at  once  they  may  be  devel- 
oped by  fatigue  of  the  retina  The  patient  is  asked 
to  look  steadily  for  a  couple  of  minutt^s  at  a  near  object 
and  then  the  field  for  red  and  green  should  be  mapped 
out,  followed  by  that  for  white,  and  vice  versa.  The 
amblyopia  may  be  so  marked  that  the  field  for  white 
and  colors  is  reduced  to  the  vanishing  point,  a  condi- 
tion  of  affairs  which  it  is  not  improper  to  regard  as 
an  anesthesia  of  the  perceptive  elements  of  the  retina 
and  in  correspondence  with  the  loss  or  perversion  of 
sensation  exhibited  by  the  skin  and  mucous  membranes 
in  other  pliases  of  the  disease.  In  such  instances  it 
rarely  happens,  even  where  the  central  vision  is  reduced 
to  1/10  or  1/20  of  the  normal,  tha  prevents  the 
patient  from  walking  about  as  if  he  i,  .d  good  vision. 
I  have  now  under  my  care  a  child  who  can  not  read 
the  coarsest  print  at  any  distance,  whose  distant  vision 
is  reduced  to  finger  counting  at  four  feet  and  whose 
color- field  and  the  area  for  white  measure  about  5  de- 
grees, and  yet  to  all  outward  appearances  she  has  good 
eyesight,  that  is,  she  does  not  stumble  over  small  arti- 
cles of  furniture  placed  in  her  path  and  her  parents 
have  difficulty  in  believing  that  her  vision  is  defective. 

My  principal  reason  for  referring  to  these  defec^ts 
in  the  visual  field,  so  well  known  to  all  of  you,  is  to 


6 


iiiBint  upon  a  cortain  form  of  examination.  Hyflte 
is  esHentially  a  fatigue  neuroBiB  and  in  the  use  o 
subjective  test  like  the  jierim^ter  one  may  raBily  obt 
evidence  that  is  ([uitr  mialeadinjr.  In  other  woi 
mapping  out  the  limits  of  the  tield  of  vision  in  a  h 
tiTope  requires  morr  time  and  patience  than  is  gen 
ally  given  to  it.  In  my  opinion,  all  uncomplioa 
caseH  t)f  hysteric  defe<'t  show  a  concentric  contract 
*  and  n  fairly  uniform  boundary  of  the  visual  tield. 
the  case  wiios*'  tield  I  show  you  there  were,  when 
was  first  measured,  several  apparently  reentrant  ang 
but  these  disappeared  when  the  patient  was  allov 
to  close  h«  r  eyes  and  rest  for  an  instant  every  thi 
seconds  during  the  examination.  I  do  not  think  t 
hand  perimeters,  or  objects  simply  held  in  front  of 
face,  should  be  used  in  examining  hysteric  patiei 
A  stationary  [)erimeter,  accurately  adjusted  sho 
always  be  employed  and  the  suspected  hystep 
should  remove  th«'  chin  from  the  rest  and  close 
eyes  fre(iuently  during  the  examination.  Moreo^ 
only  one  eye  should  be  examined  at  a  sitting  and  c 
trol  tests  must  be  repeatedly  made.  I  have  often  1 
an  opi>ortunity  to  observe  the  necessity  for  tak 
these  precautions,  and  am  convinced  that  impro 
conclusions  may  readily  be  drawn  from  the  uf 
method  of  examination. 

MoNodLAR    DIPLn.'I.A    (»R    l*«»I.V(>PIA 

is  a  curious  hysteric  phenom^n»>n,  probably  the  rei 
of  ciliary  spasm.  When  care  is  takei  not  to  sug^ 
it  to  the  patient,  it  may  l)e  developed  in  many  hys 
opes.  I  say  developed,  because,  like  defects  in 
Held  of  vision,  the  patient  is  usually  unconscioue 
the  double  vision,  as  such.  It  commonly  pres( 
itself  to  him  or  her  as  part  of  the  visual  defect  i 
the  manner  in  which  the  examination  is  carried  on 
of  ^reat  importance.  A  test  should  be  made  in  b 
a  lighted  and  darkened  room.  In  the  former,  one 
being  covered,  a  white  match  is  held  vertically  tl 
or  four  inches  in  front  of  the  uncovered  eye.     As  i 


/ 


5c, 


I  illation.     Hysteria 

IK  I    in  tlio   use  of  a 

10  may  easily  obtain 

In  otlier  words, 

of  viHioii  in  a  liyH- 

■nct'  than  is  gener- 

all   uncomplicatt'd 

centric  contraction 

hv  visual  Hc'hl,     In 

lit're  were,  when   it 

ly  reentrant  angles, 

aticnt  waH  allowt'd 

instant  every  thirty 

I  do  not  think  that 

held  in  front  of  the 

:  hysteric  patients. 

ly    adjusted  should 

ispt'cted   hysterope 

rest  and  close  the 

nation.     Moreover. 

it  a  sitting  and  coii- 

.     I  have  often  had 

Bcessity   for  taking 

iced  that  improper 

vn   from   the   usual 

I'OI.YOIM.V 

probably  the  result 
nkei  not  to  suggest 
)ed  in  many  hyster- 
like  defects  in  the 
illy  unconscious  of 
commonly  presents 
3  visual  defect  and 
ion  is  carried  out  is 
Id  be  made  in  both 
the  former,  one  eye 
eld  vertically  three 
rered  eye.     As  it  is 


slowly  moved  from  its  Hrst  position  to  a  point  three 
or  four  feet  away,  the  patient  is  asked  how  many 
matches  he  sees.  In  most  cases  the  mat(^h  will  pre- 
sent a  double  image  when  held  quite  near  the  face; 
the  images  approach  each  other  and  become  confused 
as  they  are  removed,  to  again  separate  more  and  more 
until  the  meter  distance  is  reached.  The  match  is 
again,  from  this  point,  gradually  brought  close  to  the 
eye.  when  the  same  phenomena,  but  in  reverse  order, 
will  be  manifest.  The  second  eye  is  similarly  exam-« 
inod  and,  tinally,  the  room  is  (hirkened  and  a  further 
<contr<»l)  test  is  made  with  a  small  candle  tlame. 
Sometimes  three  or  more  images  (polyopia)  are  ob- 
served and  it  is  usually  possible  to  exclude  one  or 
more  of  these  by  inter[)osing  a  card,  so  as  to  cover 
various  segments  of  pupillary  area  during  examination. 
A  few  words  about  pupilUnnj  auomnUcs  in  hysteric 
subjects,  because  there  is  much  confusion  on  this 
point.  As  a  rule,  when  either  or  both  pupils  are  un- 
usually contracted  or  unusually  expanded  the  ordinary 
retlexes  are  preserved,  that  is,  tliey  contract  when  light 
is  thrown  upon  them  and  when  suddenly  asked  to  Hx 
a  near  object,  and  they  expand  when  light  is  withdrawn 
or  when  the  jjatient  is  told  to  gaze  into  the  far  distance. 
This  is,  or  ought  to  be,  a  very  simple  matter,  but  in 
cases  of  hysteric  amblyopia  some  care  should  be 
observed  in  making  the  examinations.  The  patient 
should  be  sefited  facing  a  half-lighteil  window,  the 
unclosed  eyes  are  completely  covered  with  a  black 
cloth  and  he  is  told  to  look,  and  to  continue  to  look, 
as  if  ga/ing  upon  a  distant  object  which  has  been  pre- 
viously pointed  out  to  him.  In  thirty  seconds  the 
cover  should  be  suddenly  removed  and  the  contrac- 
tions of  the  pupils,  or  its  absence,  noteil.  The  reflex 
contraction  of  the  pupils  for  convergence  or  accom- 
modaticm  should  be  tested  in  a  light  as  dim  as  is  con- 
sistent with  the  observer's  ability  to  see  the  patient's 
impils.  Having  been  told  to  look  at  an  object  across 
the  room  for  half  a  minute,  he  is  now  asked  to  quickly 
tix  the  end  of  the  tinuer  held   four  inches   from  the 


patient's  faco.  By  means  of  these  simple  hutetVf 
devices  one  may  often  avoid  the  mistake  of  concli 
tliat  he  has  to  deal  with  a  pupil  that  does  not  res 
to  the  retiexes  mrntioned. 

I  need  not  remind  you  that  in  hysteric  ambl; 
we  frecph'ntly  tind  }>i<i('i-()psi((  n\\{\  mirrof)si(t.  Vs 
the  patient  complains  of  this  strange  symptom,  ; 
ably  due  to  irrt'gularcontractun*  of  the  ciliary  mi 
hut  it  is  often  worth  while  to  test  for  it.  A 
.lighted  candle  is  hrld  before  each  eye  of  the  pt 
at  distances  of  one,  four  and  ten  feet,  and  he  is  j 
wh«'ther  it  gfts  longer  or  smaller  in  size.  Notf 
made  of  his  answer  and  the  experiment  repeated 
day  or  two. 

A  very  common  and,  in  my  opinion,  characte 
eye-sign  in  hysteria  is  spasm  of  the  orbicularis 
so-called  blepharospasm.  When  this  is  unilatera 
accompanied  by  photophobia,  or  spasm  of  accoi 
dation.  it  is  almost  invariably  hysteric,  and  I  bt 
that  the  majority  of  the  spasms  of  the  orbicular 
of  this  character,  whether  in  Mie  form  of  blinki 
constant  winking  of  the  eyes,  or  where  the  si)a 
much  more  marked  and  involves  the  facial  mus< 


le  simple  Imt  effective 
nistakeof  coiu'ludin^ 
that  does  not  respond 

[1  liysteric  amblyopia 
il  mic}'(>psi((.  Tsually 
ange  symptom,  prob- 

of  the  ciliary  mus(rle, 
test  for  it.  A  long, 
h  eye  of  the  patient 

feet,  and  he  in  asked 
dT  in  size.  Notes  are 
^riment  repeated  in  a 


pinion,  characteristic 
f  the  orbicularis,  the 
this  is  unilateral  and 
:  spasm  of  accommo- 
ysteric,  and  I  believe 
of  the  orbicularis  are 
B  form  of  blinking  or 
r  where  the  spasm  is 
8  the  facial  muscle. 


ffl 


